Transcript Acute Respiratory Distress Syndrome

Methamphetamine:
Who Really Gets Burned
Nathan Kemalyan, MD FACS
Medical Director, Oregon Burn
Center
Credits:
Kelli Salter, M.D.
Surgical Resident, OHSU
Methamphetamine Drug Pharmacology
• A central nervous system stimulant that promotes the release of
neurotransmitters (dopamine, norepinephrine, and serotonin)
which control the brain’s messaging system for reward and
pleasure, sleep, appetite and mood
• 1500% more potent
than cocaine
• Purely a synthetic
compound
Faster, Faster until
the thrill of speed
overcomes the thrill
of death
Hunter S Thompson
Methamphetamine: Historical Aspects
Adolf Hitler
JF Kennedy
"Appalachian Methamphetamine Lab"
Pieter Boggle VIII
Methamphetamine: Historical Aspects
• 1887: Amphetamine synthesized in Germany
• 1919: Methamphetamine synthesized in Japan
• 1930-40: Performance enhancer in WWII
• 1930s: Treatment for nasal passage inflammation, narcolepsy,
attention deficit disorder, obesity and fatigue
• 1960s: First recreational use
• 1970s: Legal production > 10 billion tablets ( ~1000X legitimate
medical use)
• 1970: Amphetamine/Methamphetamine classified as a
Schedule II drug
• 1980s: Illegal street forms popularized
(injected, inhaled or taken orally)
Methamphetamine Historical Aspects
• 1988: Smokable form (ice or glass) introduced from Hawaii
• Prior to 1990s: Manufacture controlled by the “White Motorcycle
Gangs” using phenyl-2-propanone (P2P)
• 1998: Federal Chemical Diversion and Trafficking Act placed
P2P under federal control
• 2003: Ephedrine (precursor) banned in its pure form in US
(increased restriction on pseudoephedrine)
• 2004: Identification required (in many states) to purchase
over-the-counter cold medications that contain
pseudoephedrine
• Today: 90% of the Methamphetamine available in United States
transported from Mexico
Current Methamphetamine Statistics
• The second most common illicit drug used worldwide
• 35 million regular users
• 12 million Americans have tried Methamphetamine
• 40% from 2000; 156% from 1996
• 1.5 million regular users
• 2003 National Survey: 5% of 8th graders and 15% of 12th
graders have tried Methamphetamine once in their lifetime
• > 17000 clandestine labs seized in United States in 2004 (100%
from 2002 and ~ 600% from previous decade)
• Over 50 recipes extracted from Internet Search
Oregon Statistics
• Number of Methamphetamine lab seizures in Oregon increased
from 67 in 1995 to 591 in 2001
• Oregon was third in the nation for number of children (241)
found at Methamphetamine labs during 2001-2002
• 2001: 2750 children (> half of all foster cases) were taken from
parents using or making Methamphetamine
• Between 4300 and 5350 children retrieved from
Methamphetamine homes have circulated in foster homes since
2001
• 2005: 472 labs and ~ 35 Kg Methamphetamine seized in state
of Oregon (7,000,000 dosage units)
Methamphetamine Addiction Statistics
• 100 people: alcoholic drink/day X 3 weeks = 8/100 addicted
• 100 people: oral or snort Methamphetamine or Cocaine daily X
3 weeks = 14/100 addicted
• 100 people: smoke or inject Methamphetamine twice = 90/100
addicted
• Methamphetamine addict that wants to quit: After 11 months of
not using, 100% of recovering addicts will use
Methamphetamine if offered
Methamphetamine Associated
Hospital Admissions (2002)
General Impact on Burn Centers
• Need for decontamination (treat chemical and thermal burns)
• Clandestine production (“cooking”) of Methamphetamine
involves > 30 different chemicals
• Increased incidence of trauma from explosions/projectiles
• Emergency medical personnel injury
• Withdrawal (higher sedation/narcotic use)
• Majority of patients uneducated and uninsured
• Extended length of stay
• Greater excision and graft failure
• Increased cost of treatment
Users and Cooks
• Cooks
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Adult Male
Undernourished
Paranoid ideation
Agitated, impulsive
Vague, Implausible history of injury
Big burns, lots of critical care
Legitimate Organic Chemistry
Production
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Highly Educated, Sober Operator
Safety-Designed Facility
Personal Protective Equipment
Process Control
Safety Practice
Decontamination Facility and Emergency
Response Plan
Methamphetamine Production
Facility
• Hotel Room, Rental Apartment, Trailer, Tent
• High School Dropout
• Judgment is Impaired-High on Methamphetamine,
Cannabis, etc.
• Agitated, impulsive, impatient
• Smoking a Cigarette
• Garbage Cans, Dry Ice and Kitchen Utensils
• No Ventilation, No Plexiglas Shield, No PPE
Users and Cooks
• Cooks
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Adult Male
Undernourished, poor dentition
Paranoid ideation
Agitated, impulsive
Vague, Implausible history of injury
Big burns, lots of critical care
• Users
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All ages
Males and Females
Uneducated
Poly-substance users
Poor social/family resources
Difficult to discharge
Erratic follow-up, rehabilitation
Burn Center behavior patterns
• Recreational User
– Goes to sleep, awakens 2-3 days later
• Hard Core User/Cook
– Tachycardia, Hypertension, Agitation
– Weeks in duration
Methamphetamine Associated Solvents
• Absorbed after ingestion, inhalation or dermal contact
• Associated Pathologies:
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Pneumonitis; Respiratory depression
CNS depression
Hepatotoxicity
Renal toxicity (pyuria, hematuria, acute renal failure)
Ventricular arrhythmias
Methamphetamine Associated Caustics
(Acids and Alkalis)
• Chemical Burns: Direct contact, ingestion, inhalation
• Associated Pathologies:
• Pneumonitis; Respiratory depression
• CNS depression
• Hepatotoxicity
• Renal toxicity (pyuria, hematuria, acute renal failure)
• Ventricular arrhythmias
Methamphetamine Associated
Metals and Salts
• Multiorgan toxicity
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Skin burns
Eye and Respiratory tract irritations
Nervous system: Headache and seizures
Gastrointestinal irritations (nausea, vomiting, diarrhea)
Renal
Hematological
Methamphetamine-Associated Burn Injuries:
A Retrospective Analysis
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Retrospective review of medical records (507 burn patients)
34 patients (6.7%) identified
• Mean Age: 31.9  7.65 years; 92% male
• 41% tested positive for other illicit drugs (excluding alcohol)
• Mean % TBSA: 18.9 %  20.72 % (range: 1.5-90%)
70.6% flame injury; 20.6% chemical injury
• Drug withdrawal: 44.1% (agitation and hypersomnolence)
• Average length of stay: 15.9  19.2 days (range 0-72)
• Mean cost/patient: $77,580 (range: $112-$426,386)
• 69.6% unemployed
• 11.8% with third-party insurance
• 44.1% uninsured without government assistance
• 44.1% supplemented with Medicaid or Medicare
• 96.8% of cost related to length of stay, %TBSA and total days
on ventilator
Danks, R. R., Wibbenmeyer, L.S., Faucher, L.D., et al. J Burn Care Rehabil 2004; 25: 425-429
The Methamphetamine Burn Patient
• Retrospective study
• 15 (2%) Age-matched and TBSA-matched patients
• Mean Age: 30  6 years
• 10 male; 5 female
• Results:
• Methamphetamine patients required at least 2-3X the
calculated volume of resuscitation, irrespective of burn size
• All Methamphetamine patients with  40% TBSA burn died
(estimated 60% survival without Methamphetamine)
Warner, P., Connelly, J.P., Gibran, N.S., et al. J Burn Care Rehabil 2003; 24: 275278
Methamphetamine Laboratory Explosions: A
New and Emerging Burn Injury
• Retrospective study
• 15 (4%) patients: Age-matched and TBSA-matched
patients to 45 patients
• Mean Age: 35.5 years (range 21-48)
• Mean burn size 36% TBSA
Methamphetamine Laboratory Explosions: A
New and Emerging Burn Injury
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87% Men
93% Caucasian
73% unemployed
73% uninsured
87% no college education
Methamphetamine Laboratory Explosions: A
New and Emerging Burn Injury
• Tox Screen
• 100% Methamphetamine
• 66% two or more drugs (opiates,
benzodiazapines, cannabis)
Methamphetamine Laboratory Explosions: A
New and Emerging Burn Injury
• Results:
• Methamphetamine patients required at least 1.5-2X the
calculated volume of resuscitation, irrespective of burn %
• 73% with inhalation injury: Mean 33 days on ventilator (17
days for control)
• Skin graft loss 33% (12.5% for control)
• Higher predicted need for sedation/pain control
• Longer hospital stay: Mean 30 days (21 for control)
• Higher mean cost/patient: $228,732 ($74,799 for control)
Santos, A.P., Wilson, A.K. Hornung, C.A., et al. J Burn Care Rehabil 2005; 26: 228-232
The Faces of Methamphetamine
“Meth Mouth”
Source: New York Times, June 11, 2005
3 years, 5 months later
“Methamphetamine:
You wished it would have
killed you the first time”
- unknown author